Healthcare Provider Details

I. General information

NPI: 1578914602
Provider Name (Legal Business Name): DIEGO MEDINA LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 11/28/2022
Certification Date: 11/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HILLMONT AVE
VENTURA CA
93003-1651
US

IV. Provider business mailing address

350 HILLMONT AVE
VENTURA CA
93003-1651
US

V. Phone/Fax

Practice location:
  • Phone: 805-233-7750
  • Fax:
Mailing address:
  • Phone: 805-233-7750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number278315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: